On an unseasonably warm September afternoon, three patients sat in Dr. Gregory Heifler’s waiting room, none of them, as it happens, exhibiting symptoms of swine flu. Despite the dire scenarios making the media rounds since the virus emerged in Mexico in March, the scene in the Montclair family physician’s office looked like something out of Norman Rockwell.
That’s not to say that Heifler is unfamiliar with swine flu; since last spring, he’s seen roughly twenty probable cases of this year’s version—also known as H1N1 or novel H1N1. While some of his patients exhibited severe symptoms—which, typically, include fever, body aches, sore throat, congestion, and cough—most received a prescription for the antiviral medication Tamiflu and were feeling better in three days, though others progressed to more severe symptoms such as respiratory problems.
As this issue was going to press in early October, Heifler’s experience was aligned with state and national trends. “Novel H1N1 appears to be relatively easy to transmit from person to person, but its severity or virulence doesn’t seem particularly high,” says Dr. Ronald Nahass, an infectious disease specialist at Robert Wood Johnson University Hospital. And we can take heart, says Jan Schwarz-Miller, director of occupational medicine for Atlantic Health, from the experience of countries in the Southern Hemisphere during their recent winter, which doctors believe is the best predictor we have of the flu’s behavior in the months to come. “We saw some shortage of supplies, hospital beds, and antivirals,” she notes. “But what’s somewhat reassuring is the fact that the flu started there in early winter, and the incidence and prevalence came down quite quickly, about seven weeks later.”
Of course, no one can be certain the same thing will happen here. Influenza viruses are mercurial, subject to mutation and reassortment with other flu viruses, which can render them potentially more—or less—virulent. A report by the public advocacy group Trust for America’s Health predicted that as many as 42,000 New Jerseyans could require hospitalization for swine flu this winter, overwhelming the state’s supply of hospital beds.
There’s little doubt, says Heifler, that “activity will increase as the temperature drops in November.” But whatever trajectory 2009 H1N1 takes, the precautions necessary to avoid it, and its spread, are likely to remain largely the same throughout the winter months.
Vaccination: who should get it, where to find it, how to pay for it.
By late October, the distribution of the H1N1 vaccine should be in full swing. Of the 195 million doses ordered by the federal government, New Jersey should receive an initial 1.2 to 5.2 million, with more to follow. (The state’s population is about 8.7 million.)
Research in the United States and Australia indicates that for people over age 9 a single dose is all that is required. That means our supply should be sufficient for the people who are presumed to need it most: pregnant women (at higher risk of complications); caregivers of children younger than 6 months (since those children can’t be vaccinated); health care workers; anyone between 6 months and 24 years (the age group most vulnerable to the virus); and those with serious health conditions. (The elderly have not been found to be unusually vulnerable to H1N1.)
“We’re hoping that whatever vaccine supply we get will be enough to cover everyone who wants it in New Jersey,” says Dr. Susan Walsh, the state’s deputy commissioner of health, “but we’re being very careful to make sure that we use the first supplies for our targeted vulnerable population.”
If you want the vaccine, you may or may not find it at your family physician’s office. The state health department is shipping it to 2,353 sites, including hospitals, clinics, and local health departments; from those sites, it will make its way to provider sites like doctors’ offices and pharmacies.
“It’s a challenging type of distribution that’s being conceptualized and rolled out as we go along,” says Dr. George T. DiFerdinando, manager of the New Jersey Center for Public Health Preparedness at UMDNJ. “You may have to be a classic, Jersey-motivated consumer and go to where the vaccine is.”
Paying for the vaccine is likely to be less of a challenge: The state has a commitment from its largest insurers to cover H1N1 vaccination costs—even for consumers whose plans don’t normally reimburse for vaccination.
Also important: Doctors recommend a separate vaccine against seasonal flu—a bout of which could weaken your immune system and make you more susceptible to H1N1. Assuming they are available, you can get both shots at the same time.
Who is immune?
You were vaccinated. Can you still come down with the flu? The best seasonal flu vaccines are about 80 percent effective, and after a dose of any vaccine, immunity builds up gradually over a period of weeks. So you can still get the flu, but the symptoms of people who get sick after being vaccinated generally are not as severe as those who were not vaccinated.
What if you or someone in your household has already recuperated from a case of 2009 H1N1? “Even if you tested positive in your doctor’s office to flu A [which includes H1N1], you can’t assume you’ve had actual 2009 H1N1,” says Schwarz-Miller. Swine flu can be diagnosed with certainty only through a genetic test known as an rPT-PCR Flu Panel, but it’s generally used only as an epidemiological tool. So if you want to avoid the virus—even if you’ve been sick with flu—your best bet is to get vaccinated.
“With flu in general, it always makes sense to get the vaccine,” says Dr. Fred Jacobs, executive vice president of the St. Barnabas Health Care System and director of the St. Barnabas Quality Institute, because there’s no way to predict how long the season will last. And H1N1, unlike seasonal flu, never took a summer vacation. This year, says Glenn Paulson, director of the New Jersey Center for Public Health Preparedness at UMDNJ, “I think it’s probably going to last at least as long as the normal flu season—into the spring— and possibly longer.”
What if you—or your kids—get sick?
Is it a cold? The seasonal flu? H1N1? According to Dr. Peter Gross, chief medical officer at Hackensack University Medical Center, if symptoms are severe, call your doctor immediately. Why? In order to get the benefits of flu-mitigating antiviral drugs like Tamiflu, you need to start taking them within 48 hours of becoming symptomatic.
Your doctor will likely tell you to stay home until you have been fever free, without the use of fever-reducing medicine, for 24 hours. A study out of Laval University in Quebec found that patients with H1N1 were able to transmit the virus longer than doctors had previously suspected—as long as eight days after symptoms began.
The Usual Precautions
Hand-washing may not sound like an effective tool against a pandemic, but most doctors endorse it heartily. “It’s incredibly important,” says Gross. Even though H1N1 is spread largely through respiratory droplets, Gross explains, those droplets can end up on your hands, or someone else’s. And yes, alcohol hand sanitizers work well against flu.
Above all, avoid panic, which is neither helpful nor healthful. “When people hear ‘pandemic,’ they automatically think the worst,” says Jacobs. “But pandemic only implies easy transmissibility and widespread disease. It doesn’t necessarily imply severity”—a caveat, we hope, that will have all of us breathing a little easier in the new year.
An H1N1 Primer
It was “swine flu,” then “novel H1N1,” and now the medical community is calling it “2009 H1N1.” That’s because in previous years we have seen both swine influenza (a flu virus that causes disease in pigs, and sometimes in humans) and H1N1 (a subtype of flu). It’s this year’s variety of swine flu that’s new to the world.
Why the concern about this particular strain? First, it’s a “novel” flu virus—a new mutation to which many people possess little or no immunity. By definition, all pandemics—diseases that affect a large number of people worldwide—are caused by novel viruses. Second, it showed particular virulence when it first appeared in Mexico (unmatched, to date, in any other locale). And third, doctors realized that this new H1N1 was displaying some striking similarities to the virus that caused the Great Flu Pandemic of 1918.
“The very young were affected and died, and fewer elderly died than you would have expected because they were probably immune,” says Dr. Peter Gross, chief medical officer at Hackensack University Medical Center.
Fears were also stoked by the severity of another recent virus that, like swine flu, is capable of animal-to-
human transmission: an avian flu known as H5N1, which appears to carry a strikingly high mortality rate. But unlike 2009 H1N1, H5N1 has, to date, only been transmitted from animals (birds, in this case) to humans, not from one human to another.
In addition to being easily transmissible, 2009 H1N1 is a competent world traveler: According to the World Health Organization, this particular swine flu strain has spread more rapidly than any other in history, effectively making its way around the globe in six weeks—a circuit that has historically taken about six months.
We don’t know to what degree that speed can be attributed to the nature of the virus itself or to the greater prevalence of international travel. What we do know: So far, this novel flu has been no more severe than the seasonal flu, which typically infects some 5 million people worldwide and is responsible for 250,000 to 500,000 deaths annually—most, in industrialized countries, among those 65 and older.
And by the way, those paper masks that were ubiquitous on the streets of Mexico City last spring?
According to a recent study, they are ineffective against spreading H1N1. On the other hand, coughing into a tissue (or your elbow) works.
Leslie Garisto Pfaff is a frequent contributor on health and education.